Useful Activity or Busy Work?

By William A Hyman, ScD; and Robert J. Latino

We have been thinking about how root cause analysis (RCA) is conducted and how effective is it when properly performed. Relevant factors include the actual methodology, the skill of the practitioners, and the seriousness of purpose. Ultimately, it also includes how the results of the RCA are used to quantifiably improve safety (as opposed to being content with minimal compliance requirements).

First it must be noted that RCA can take many forms. It is not a single, well-codified process; it tends to be more general (i.e. discovering the underlying causes of an adverse event). A further purpose of RCA is often missing: to implement systemic changes designed to prevent the identified latent root causes from recurring (either individually or in adverse combination). Another purpose is to measure the effectiveness of whatever changes are put into place against patient safety metrics. How is the patient better off as a result of the implemented recommendations from our RCA?

RCA Methodology

Even with good purposes in mind, the methodology used affects whether an RCA effort is effective or not. In this regard, attention should be paid to how the RCA is conducted, the validity of the method, and the basis for using it.

It is reasonably clear that people leading an RCA need to be well-trained in the purpose and methodology, as well as unbiased (e.g. they should not have something to lose or gain by the outcome of the analysis). Without such training, it is unlikely that even a good process will lead to a comprehensive and useful outcome. In addition to knowing the RCA process, subject matter expertise (SME) is necessary to understand the context of the event, how such events have been addressed elsewhere, and the likely effects of a proposed intervention (assuming the RCA gets that far). Personnel with SME should be represented on the RCA team, where their input and potential bias can be vetted by the lead investigator. This can be accomplished by validating SME hypotheses using hard evidence as opposed to letting hearsay or proposals fly as fact.

Seriousness of purpose deals with the attitude of the leadership hierarchy and the participants, and commitment to actionable findings, compliance, and most importantly, to quantifying direct patient safety results. A key limitation has been the attitude that RCA is an exercise undertaken for the sole purpose of meeting a requirement (i.e. doing this because it is the right thing to do vs. doing this only because someone is making us?). Related to attitude is the time commitment to do an RCA that matters, in a timely fashion. If RCA participation is an add-on to an already too-busy schedule, participants may not give it adequate attention. Unfortunately, this is true for many of those charged with leading RCAs. Such individuals need to understand the full potential and value of a properly conducted RCA. When they do, they will see it as a tool that will help them “clear their plates.” Analysts need to view RCA as a benefit, not a burden. That will be the motivation for effectiveness.

Doing something primarily because it is required is not the same as doing it because you have the knowledge to do it well, and the understanding that doing it well can make a real difference. Unfortunately, RCA is poorly defined in the healthcare industry and practiced with variable skill, which results in inconsistent performance. RCA has its proponents and detractors. Some do it because they have to, and some do it because they want to. It is our experience that those who want to do RCA are the most effective and successful. This situation parallels other safety interventions, such as time-outs, crosschecking, and hand washing. If you want something to be effective, know what you are doing and do it with commitment to outcomes rather than a commitment only to the doing!

---

William Hyman is professor emeritus of biomedical engineering at Texas A&M University. He now lives in New York, where he is adjunct professor of biomedical engineering at The Cooper Union. Hyman may be contacted at w-hyman@tamu.edu.

Bob Latino is CEO of Reliability Center, Inc. (www.reliability.com), a consulting firm specializing in improving equipment, process, and human reliability. Latino may be contacted at blatino@reliability.com.

Hyman, W. A., & Latino, R. J. (2014). Useful activity or busy work? [Root cause analysis]. Patient Safety & Quality Healthcare, 11(6), 10–12.